Similar to the international trend [1], the occurrence of substance use and substance use disorder (SUD) is rising in South Africa [2]. Alcohol and cannabis are the most commonly used substances in South Africa, and the use of illicit drugs continues to rise [3]. In sub-Saharan Africa, South Africa is by far the largest market for illicit drugs [4], and it has one of the world’s highest opioid addiction rates and the fourth highest rate of drug offenses [5,6]. [7] identifies harmful substance use as a fuel or catalyst for crime, reduced productivity, unemployment, family violence and the escalation of chronic diseases such as HIV. Despite negative consequences of substance use, there is a wide substance use treatment gap as people do not present themselves for SUD treatment [8]. Previous research has attributed the treatment gap to a wide range of attitudinal and contextual barriers [9,10]. In South Africa, complicated patient admission procedures, lack of awareness of treatment services, stigma, and perceived lack of treatment need have been identified as prominent treatment barriers [11,12]. There is a need for ongoing research on treatment barriers in South Africa since most of the research done is about a decade old and may not be relevant in the current context.
Attitudinal barriers
The main attitudinal barriers identified in previous research are fear of stigma, privacy concerns and lack of perceived need for treatment [13]. Research has consistently shown that stigma is one of the most significant barriers to substance use treatment [14,9]. Typical of most disorders or illnesses that reach epidemic proportions (e.g., HIV and AIDS), the labelling of and discrimination against victims ultimately drive the victims to hide their illness to avoid discrimination, and this prevents them from seeking healthcare [14]. In South Africa, more stigma is associated with people who abuse substances than with people who live with other mental disorders, and this is partly attributed to personal culpability associated with SUDs [15]. The use of heroin, locally known as nyaope or whoonga, is highly stigmatised, leading to marginalisation of users, and rejection by their families and communities [16]. It has been observed that greater stigma is also attached to particular treatment methods, such as opioid substitution treatment (OST) [17], and other harm reduction interventions such as needle-and-syringe-exchange programmes.
Privacy concerns and lack of perceived need for treatment have been documented to hamper treatment utilisation among individuals living with SUDs [18]. Young adults are more likely than their older counterparts to report privacy concerns [18], as they want to avoid inquiry into and monitoring of their substance use [19]. Research in South Africa has found that those from low socio-economic backgrounds, where prevalence of substance use is often higher, are more likely not to know that they need help [20,21]. They have learnt to justify, rationalise and normalise (as explained in cognitive dissonance theory) substance misuse as part of their lives and daily routine [22].
Contextual barriers
Contextual barriers refer to structural factors that are perceived to preclude treatment utilisation. These include cultural factors, inadequate treatment facilities and personnel, fragmented services, and lack of information on treatment services available.
Culture is not exhaustively defined by language, ethnicity, nationality or race, but goes beyond that to focus on subcultures that are organised around shared values, beliefs, customs and traditions [23]. Cultural factors may mediate substance use and misuse behaviour, especially when substance use is related to cultural rituals and associated with strong masculinity [24]. Such cultural perceptions may ‘normalise’ substance use and misuse in these cultural groupings, which precludes people from perceiving a need for treatment [25]. Drug subcultures alienate themselves from mainstream society and establish social ties among people using substances. University or college students have been known to form such drug subcultures [26]. The Cape Flats drug subculture in South Africa is a prominent example [27] and is characterised by gangsterism and a strong culture of drug use and competition for control of a lucrative drug trade. One can argue that the norms and values of these cultural subgroups catalyse increased substance use and cause the users not to develop a sense of the need to regulate their use or seek treatment.
Global shortages of substance use treatment facilities and adequately trained healthcare personnel have negatively impacted on mental healthcare delivery, especially in low- and middle-income countries [28]. These shortages are largely due to a lack of public funding for mental health services [29]. In South Africa, certified training for addiction counsellors is limited and there is no provision for an addiction specialty for health professionals [30].
Fragmented services relate to characteristics of the healthcare system that impede treatment utilisation [31] such as flawed administrative practices, ineffectual laws and regulations, poor funding, poor data management systems, and poor staff training. In South Africa, slow substance user registration and long waiting lists have been identified as impediments to treatment utilisation [32]. The lack of competent and adequately trained mental healthcare practitioners who can productively engage and collaborate with patients dissuades substance users from seeking treatment [33]. Research shows that people using substances prefer a collaborative relationship with practitioners to set out goals and negotiate a treatment plan [34].
Information on substance use treatment options, especially on harm reduction strategies, is often limited in communities [21]. In South Africa, [11] have found that limited information about available treatment is one of main reasons why people using substances do not seek treatment. Information about treating opioid dependency using OST is especially limited [11,21].
In order to address the paucity of rigorous research on substance use treatment barriers in South Africa, this study aimed to explore and obtain an in-depth understanding of barriers to treatment among young adults living with SUDs, with a view to develop evidence-informed intervention strategies.
The objectives of the study were to:
1) explore what young people using substances perceive as barriers to treatment utilisation; 2) measure the relative strengths of different treatment barriers in impeding health services utilisation, using an instrument that has been adapted for the context; and 3) develop evidence-informed intervention strategies to enhance treatment options and accessibility of treatment for substance users.